Instant Access Colonoscopy Insurance Verification

This form was created to help you verify your insurance benefits.

This form needs to be completed in its ENTIRETY (prior to your prep appointment), or we will not bill your insurance for the procedure, and you will be expected to pay up front.

Our colorectal surgeons are now preferred with Cigna, Aetna, and Premera

Please have the following information available when calling your insurance company:

Insurance Company Name

Insurance Company Phone Number (on back of your card)

Patient Name

Date of Birth

Policy Holder Name

Date of Birth

ID Number

Name of representative you talked to

Date & Time

Our information is the following:

Alaska Colorectal Surgery 2751 DeBarr Road, Suite 280 Anchorage, AK 99508

TAX ID: 92-0177040

June M. George, M.D. - NPI: 1891735346; Kerrie R. Bossard, M.D. - NPI: 1548267032; Daniel C. Rossi, D.O. - NPI: 1568660835

I understand that the above is an estimate only. I understand that I am financially responsible for any balances, after insurance pays, and that they must be paid within 10 days. Full payment will be required at the time of pre-op appointment, if this form is not completed in its ENTIRETY.

Signature of Patient/Legal Guardian

Date

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